International Dysphagia Diet Standards

A Premier Foods guide to International Dysphagia Diet Standards

Premier Foods guide to the International Dysphagia Diet Standardisation Initiative Welcome to the next step in our journey of assisting caterers to provide creative, tasty and inspirational recipe solutions for dysphagia sufferers that will ensure dignity in dining. In this latest guide, we aim to outline the new international dysphagia guidelines, and provide tips and advice for caterers as the industry begins to adopt the new framework. The International Dysphagia Diet Standardisation Initiative (IDDSI) standardises the framework for texture modified foods globally. Our guide to these new standards has been designed to equip caterers with creative and inspirational recipe ideas which follow this new framework. The recipes are cost-effective, using ingredients and equipment that can be found in the average commercial kitchen, making it as easy as possible to meet the needs and provide sufferers with delicious meals that will ensure dignity in dining, and meal times are an occasion to look forward to. We know that there are a number of challenges in catering for a dysphagia diet and we are proud to continue our collaborative work with customers to ensure the most enjoyable experience possible for those suffering with dysphagia. With the day-today challenges of managing budgets, meeting the requirements of specialist dietary needs, all whilst ensuring a welcoming healthcare or care home environment, there is a real need for menu solutions and products that you can rely on. Contents 3... 6. 7. 8.. 12. 1. 16. 18. Introduction Background Living with dysphagia What are descriptors? So what s new? Preparing meals Starting the day right Hearty lunch time Tasty teatimes Delightful desserts Sensational snacking Most people look forward to mealtimes as a break in the day, an opportunity to socialise and relax as well as enjoy a range of food and drink. Those who have swallowing difficulties will tend to have the opposite experience seeing mealtimes as tedious, embarrassing, tiring, unenjoyable and sometimes frightening. Difficulty with swallowing is found in more than 12% of healthy older people with a reduction in muscle strength, alterations in the sense of taste and saliva. Furthermore, dysphagia affects 0-70% of patients having suffered a stroke, 60-80% of patients with progressive neurological diseases such as Parkinson s disease, as well as 60-7% of patients undergoing radiotherapy for head and neck cancer. Dysphagia is also identified as a key risk for those with learning difficulties, as well as up to 7% of people with dementia, and it has been estimated that more than 1% of older people in care homes have difficulty swallowing. Swallowing difficulties are associated with reduced health and well-being and can cause high levels of anxiety to relatives and carers. Improving the experience of individuals with these challenges can be highly rewarding as it can make a huge difference to their quality of life. Some individuals will have such significant dysphagia that they will need to have a detailed assessment of this condition conducted by a Speech and Language Therapist, who will review risks and advise regarding textures and consistencies of meals. We often take swallowing for granted. There are many different reasons associated with its disruption and we need a multidisciplinary approach to ensure that individuals that have these challenges can improve their quality of life by looking forward to mealtimes. I am delighted that the new range of recipes from Premier Foods will extend the options that can be offered. Pam Enderby, MBE, PhD, DSc (HON), MSc, FRCSLT Prof Emeritus, University of Sheffield Pam Enderby is Emeritus Professor of Community Rehabilitation at the University of Sheffield. She is a qualified Speech and Language Therapist and has combined research with clinical practice. She is the author of 1 books and has published 200 peer-reviewed journal articles. Her areas of research include: outcome measurement, assessment, evaluation of rehabilitation and speech and language therapy. Pam was awarded a Fellowship of the College of Speech Therapists and has been honoured with an MBE for services to speech and language therapy. This document should be used alongside the IDDSI Food Textures descriptors, individual advice from a Speech and Language Therapist or health care professional. Dysphagia International Standards 3

Background Dysphagia in the UK Dysphagia can affect individuals of all ages and can be short or long term with figures showing that 22% of over s suffer. Dysphagia in extreme cases can be life-threatening, causing chest infections, malnutrition or dehydration. The prevalence of dysphagia is likely to increase over the next three decades as our population continues to get older. The Office of National Statistics has shown that between 197 and 201, the number of people aged 6 and over grew rapidly to make up 18% of the UK s total population, with people over 7 increasing by 89%. The International Dysphagia Diet Standardisation Initiative (IDDSI) The International Dysphagia Diet Standardisation Initiative (IDDSI) was founded in 2013. Its aim is developing new global standardised terminology and definitions to describe texture modified foods and thickened liquids used for individuals with dysphagia of all ages, in all care settings. Always use mediums that will use the minimum amount of liquid possible and that will complement the flavour profile of the meal. Malnutrition People requiring dysphagia diets have a greater risk of malnutrition because of numerous factors such as reduced appetite or the inability to eat independently. Many care homes and hospitals are relying on puréeing in order to deliver meals for dysphagia patients but it can impact the nutritional content of foods with a reduction in vita and fibre content during the process. By the age of 7, 1 in women and 1 in 6 men will have suffered a stroke in the UK of these, 37% are predicted to develop some form of dysphagia Pioneering Healthcare Solutions from Premier Foods In 2012 Premier Foods began its journey to launch a ground-breaking new Healthcare Solutions Programme which reappraised the catering offered across the industry to ensure the nutritional needs of those suffering with dysphagia were being met. The programme initially focused on diets required for dysphagia alone, but momentum gathered and solutions are now being developed for dementia and diabetes sufferers. The programme has included a mix of practical training, workshops, on-going advice and support to the industry, along with our Dysphagia Chef of the Year competition in 2016 a first for the industry, which celebrated and showcased the skills of chefs working in this specialist area. We have already run over 0 training courses since the initial launch of our Healthcare Solutions Programme in 2012 with group care home operators, NHS trusts, local authorities, independent businesses and individual caterers. Whilst we have made progress in demystifying these often misunderstood conditions such as dysphagia, the hard work doesn t stop there. We will continue to work collaboratively with the industry to understand the needs of caterers and the real-time challenges they face through all stages of the supply chain, ensuring our solutions always deliver a fresh and inspiring approach. The next stage in our journey is to provide support to the industry as the new IDDSI framework is adopted. All of the recipes within this guide use the new international descriptors and have been provided to enable care homes and hospitals to provide nutritious and exciting meals that meet the new globalised descriptors. The recipes also include Premier Foods products that caterers may already have in their store cupboard including: Bisto, Ambrosia, Angel Delight and McDougalls. Living with Dysphagia Living with dysphagia can be difficult in terms of malnutrition, danger of choking, anxiety about having to eat something different to your peers, and is becoming more prevalent in today s society. The condition varies from person to person and some individuals are at a greater risk of malnutrition, dehydration, aspiration pneumonia and choking as a result. Dysphagia can impact on an individual s quality of life as a result of anxiety, embarrassment and loss of taste and smell. Therefore ensuring that individuals with dysphagia have a nutritious, appetising and safe meal is essential both in terms of maintaining an individual s well-being and quality of life. Whist there are promising treatments being developed, modification of food texture and liquid in line withthe International Dysphagia Diet Standardisation Initiative (IDDSI) Framework is an essential part of dysphagia management. The eating environment Environment has a big role to play in making a person feel relaxed which can impact how much someone will eat. Ensure the area is attractive and homely to stimulate the senses The room should be well lit. Contrasting colours give definition between table, plate and food Ensure the eating environment is calm and relaxing as a noisy environment can be distracting Presentation Food looks most appealing when separated on the plate and when colourful and vibrant. This is easy to achieve if foods are modified separately and plated to be visually appealing. Top tips for varying presentation All descriptors are explained in detail overleaf Piping bags Piping bags are easy to use and will hold Level purée and some Level minced and moist textures, protecting food from forming skins. With a little practice and by altering the size of the hole, a range of shapes and replications of common foods can be achieved. Nozzles can be used to give shapes interesting textures Food moulds Food moulds are available in the shape of many common foods and can be used for Level and some Level minced and moist textures. Simply process the food to the desired texture, fill the moulds and then freeze. Once frozen they can be popped out and stored. To regenerate, plate the frozen shapes and steam until heated thoroughly Shaped cutters Cutters are available in a variety of shapes and sizes, from geometric shapes like circles, squares and rectangles to the shapes of more fun things. Oil the cutters first, fill using a piping bag and then remove. Again, this works best with Level purée and Level minced and moist textures but can also be used with Level 6 soft textures too Quenelles Level and Level textures can be shaped into quenelles using two spoons. This shape is more attractive to the eye than when food has been allowed to drop off a spoon Layering Level Level and Level 6 textures can all be layered in oiled cutters or glass dishes. This enhances the visual appearance and is a simple effect. Use a piping bag for Level, a spoon can be used for other textures Dysphagia International Standards http://www.softerfoods.co.uk/will-dysphagia-affect-uk-population-future/ Dysphagia International Standards

What are descriptors? Previous descriptors: B Thin Purée Dysphagia Diet Food has been puréed or has a purée texture which does not require chewing, it is a thin purée that is smooth throughout with no bits C Thick Purée Dysphagia Diet Food has been puréed or has a purée texture which does not require chewing, it is a thick purée that is smooth throughout with no bits Thin Flows fast like water and can be drunk through any type of teat/nipple, cup or straw as appropriate for age and skill Descriptors detail the types and textures of foods needed by individuals who have oropharyngeal dysphagia (swallowing difficulties) and who are at risk of choking or aspiration (food or liquid going into their airway). The descriptors provide standard terminology to be used by all health professionals and food providers when communicating an individual s requirements for a texture modified diet. Dysphagia Food Texture Descriptors which have been previously used within the industry are: New descriptors: Within the IDDSI Framework, the food textures are: 0 D Pre-mashed Dysphagia Diet Food is soft, tender and moist which needs very little chewing, it has been mashed up with a fork before serving, it is usually very thick, smooth but non-pouring E Fork Mashable Dysphagia Diet Food is soft, tender and moist but needs some chewing, it can be mashed with a fork, it is usually very thick, smooth but non-pouring So, what s new? The new descriptors according to the IDDSI framework provide additional detail, further assisting healthcare professionals who are catering for patients who have varied levels of swallowing difficulties. Dysphagia isn t a one size fits all condition, and patients require different levels of texture modification. A review of the existing standards has resulted in a framework that is culturally sensitive, measurable and applicable to individuals of all age groups in all care settings. The new framework consists of eight levels; zero to seven (as opposed to four), where drinks are measured from Level 0 to Level, and foods are measured from Level 3. The aim of the IDDSI is to provide standard terminology for descriptors globally. Before this standardisation, there was a major barrier to research in the dysphagia field. Terms like, Thin Purée Dysphagia Diet in the UK may not translate to liquid consistencies in other countries around the world, whereas the new IDDSI provides clear and fully defined descriptors which can be used and translated worldwide. The key differences The new IDDSI framework now includes liquids and regular food to provide context The old descriptors were based on a consensus of expert opinion. The new framework has been developed after much research and collaboration across the world and each level is based on evidence There are now eight levels of texture modified diets from 0 = Thin (a drinkable liquid which flows fast like water) to 7 = Regular (normal everyday food with a variety of textures) The levels are identified by numbers, text labels, and colour codes to facilitate uptake in all care settings A category for transitional foods is provided Testing descriptors No special equipment is needed to test the correct consistency of the food, making the guide simple and accessible to everyone whether in a domestic kitchen or a large commercial catering environment. More details about testing methods can be found on the IDDSI website: http://iddsi.org. 1 Slightly thick Thicker than water, flows through a straw, syringe, teat/nipple but requires a little more effort to drink than liquids Feeding safety routines 2 Mildly thick Pours quickly from a spoon, but slower than thin drinks There is a cross over with food and drink between Level 3 and Level Pam Enderby, MBE, PhD, DSc (HON), MSc, FRCSLT Prof Emeritus, University of Sheffield 3 6 7 Liquidised/Moderately thick Can be drunk from a cup but cannot be piped, layered or moulded on a plate as it is too thin. No oral processing or chewing is required Puréed/Extremely thick Usually eaten with a spoon, can be piped, layered or moulded but does not require chewing. The food should fall off the spoon in a single spoonful when tilted and continues to hold shape on the plate Minced & Moist Can be eaten with a fork or a spoon, can be scooped and shaped on the plate, small lumps visible within the food but these lumps are easy to squash with tongue Soft & Bite-Sized Can be eaten with a fork, spoon or chopsticks (depending on hand control) and can be mashed/broken down with pressure from a fork. Chewing is required before swallowing Regular Normal, everyday foods of various textures that are developmentally and age appropriate IDDSI Framework: International Dysphagia Diet Standardisation Initiative TRANSITIONAL FOODS FOODS REGULAR SOFT & BITE-SIZED MINCED & MOIST PUREED LIQUIDISED 0 1 2 3 6 EXTREMELY THICK MODERATELY THICK MILDLY THICK SLIGHTLY THICK THIN 7 DRINKS Pam has compiled these tips to help put together safe feeding routines for your patients and residents Conscious level No-one should be given food or drink if unconscious or semi-conscious. Alternative nutritional and hydration options should be discussed with the responsible clinician Distraction Reduce distractions at mealtimes to facilitate concentration and awareness Time Allow adequate time to support the individual to eat and drink. Consider the use of insulated containers to maintain the temperature of food for those people whose mealtimes may be prolonged Positioning People should sit upright for all snacks, meals and drinks. People should remain sitting upright for at least 30 minutes after a meal to avoid reflux Oral Hygiene It is of key importance to note that people with swallowing difficulties often have poor oral hygiene which can lead to increased likelihood of chest infections. Ensure the mouth is clean and free from residue at the end of the meal. Encourage a clearing swallow, a saliva swallow or a drink of water to assist in clearing residue from the mouth. Cleaning teeth and mouths at intervals during the day is good practice Carer position The carer s position should be at eye level so that signs of difficulty can be observed as well as being able to provide verbal prompts and encouragement. Sitting beside the individual may lead them to turn their head which may make swallowing more difficult Utensils Ensure you have the correct utensils identified for the individual to facilitate a safer swallow and improve sensory awareness Glasses and hearing aids Swallowing requires multi-sensory stimulation. Food should be visually appealing in its presentation and smell appealing in order to stimulate the appetite (and salivary flow) Dentures Dentures, if worn, should fit well. Be aware that some individuals prefer to eat without their dentures and softening the diet may help Modifying Diet Texture modification is common in clinical practice. Modifying diet and adding extra sauces, gravy or custard makes chewing easier for those who are frail or have reduced masticatory skills 6 Dysphagia International Standards Dysphagia International Standards 7

Dysphagia A practical guide to preparing meals Eating nutritious and well-presented food is a vital part of our everyday lives and this is no different for those who need to have their food texture modified. Modifications of food range from thin and thick purées, finely chopped soft foods, moistened foods, to naturally soften foods whether cooked or raw. Our experience shows that all textures can be delicious and presented in appetising ways that will enhance the lives of those who need them. Flavour The modification of foods can affect their flavour. Foods can become bland and lose the intensity of sweet or sour flavours which are incredibly important when making meals delicious. It is important to taste the food once it has been modified to ensure the correct seasoning. It is not only for appearance that modified foods should be kept separate (see page 11 for presentation tips), if foods are mixed together, so is their taste profile, which sufferers may find harder to digest. They will therefore eat less. By separating the components on a plate, more food will be consumed, as each mouthful is more interesting for longer. Cooking methods There are different ways of creating texture modified meals and methods can change depending on the ingredients you are using and the serving texture you are looking to achieve. Poaching, steaming or braising foods will keep them soft for puréeing. Grilling, baking or roasting foods will boost the flavour but any crust or skin will need to be removed before serving, adding preparation time and increasing wastage. Foods will then either require thickening up or thinning down to the correct descriptor. Steaming, poaching, boiling and braising methods add moisture during cooking, which keeps ingredients soft and makes modifying the texture easier. For Level 3 to Level 6, any of these cooking methods can be used. for Level and Level 6 will need to be cut into the appropriate particle size and cooked and served with a thick sauce. For Level 3 and Level, ingredients will need to be cooked in the same way then fully puréed to the required consistency. It is essential Level 3 and Level foods are totally smooth so sieving foods is recommended. Grilling, baking, roasting and frying foods are great for adding flavour but are more challenging methods to modify the texture to the required consistency. These cooking methods provide direct heat which can dry food out. A crust can form in the cooking process and ingredients become harder as a result. With a little imagination, these methods can still be used with some slight adaptations. For example, for roast meats choose a fattier cut such as a shoulder and slow roast it this will keep the meat moist during cooking. Other ingredients can be cooked with one of these methods, and then finished in a sauce or gravy to soften the texture before modifying. Thicken up If using thickening powders it is important to allow time for rehydration as some powders will take a few minutes to do this. It is best to leave this to stand, then test against the descriptor checklist before serving. McDougalls Thickening Granules can be used, or the following Premier Foods products can also help thicken up your meals: In addition to Premier Foods store cupboard products, there are other thickening agents available. Our chefs at Premier Foods use a number of these, including Sosa products, which have been used in recipes throughout this guide. Why Sosa? Sosa products is a functional ingredient that offers solutions for caterers when creating dysphagia modified meals. All prescription thickeners should be treated as a medication. It should be stored appropriately and only used for the person named on the prescription. Having Sosa products available in your kitchen allows you to cater for dysphagia sufferers efficiently, whilst keeping nutritional value. Our top five Sosa products are: Pro-pannacotta egetal Setting Powder Instangel Gel Crem Hot Gel Crem Cold There are also a number of intense flavourings and aromas available from Sosa, which is particularly important for those who may have lost their sense of taste. Thinning down When adding liquid to puréed foods, it is important to consider that this will reduce the flavour and also dilute the nutritional value of the dish. To enhance flavour, you could use stock or gravy to thin down the dish. Alternatively, try using the following products which will also add nutrition and calories to your dish: Milk Yoghurt Custard Cream Investment in a good quality food processor or blender will improve the consistency of purées as well as save you time in the kitchen, particularly when puréeing fibrous foods such as meat products. When using a food processor or liquidiser, overfilling will result in an inconsistent purée, whilst trying to purée too small an amount will not work, as the blade will not reach the food. Factors that can change the consistency of puréed foods The temperature at which it is puréed If food is puréed hot, it will require less added liquid to reach the same consistency than the same food that has been puréed chilled. Food items that contain natural gelatine such as animal products will be firmer when cold and become more fluid once reheated The temperature at which the food is stored A cold dessert may thicken up if refrigerated for several hours so care needs to be taken that the food is the right consistency when served Reheating method Reheating may produce a crust or skin so it is best to reheat foods in a steamer or regen oven whilst covered, to prevent drying out Always ensure that food has reached the core temperature and that correct procedures have been followed. To ensure safety, always check the consistency and temperature of meals at the point of service. Foods that don t work well: Syrups Fruit Juice Condensed Milk Fibrous vegetables such as leeks Foods with pith or skin, such as grapes or peas Anything that changes texture in the mouth, such as jelly or water melon Floppy foods such as lettuce or cucumber James Clear, Hotel Services Manager (South), Care UK As Hotel Services Manager for the South, as well as the Care UK Culinary Lead, I am responsible for 60 care homes across the South of the UK. As part of my culinary role, I am responsible for ensuring the chefs across each operation are fully trained in delivering top quality meals to our residents, which meet any dietary needs, including texture modified meals for those who suffer with dysphagia. We have a number of residents across our estates who experience this condition, and we have worked extensively with Premier Foods to ensure our teams are properly trained to cater for the specialist Top tips for catering for dysphagia patients We have worked with experts in the industry to develop this guide, including Preston Walker, Managing Director, from Oak House Care Home, who has provided his top tips for catering for dysphagia patients. Create dishes on your menu that can be easily adapted for a variety of texture levels. This will save time in the kitchen and give you the ability to offer the same menu choice to all residents and patients When creating dysphagia foods, consider the individual components of the dish and whether they can be modified separately. This will ensure the taste and presentation of the dish is as close to the original as possible Think about the cooking method how can the best flavour be achieved and what is the best method to modify the texture effectively? Will cooking the dish at a lower temperature for a longer period of time make the dish softer and easier to purée? Season food throughout the cooking process to aid the flavour profile of different foods. Good seasoning is hard to achieve after cooking, particularly if foods have been diluted with liquids Presentation is key as we eat with our eyes! Present foods so visually they look as close to the original dish as possible Always check the consistency of foods against the IDDSI framework and texture requirements. Ensure checks are made at the point of service as foods can change texture when they are reheated and stored in hot trolleys for periods of time, making them inappropriate for residents and patients Never serve your patients or residents food that you are not prepared to eat yourself! needs of these residents. The training Premier Foods has offered us has been invaluable, and the materials its team has produced have gone into all of our sites and are regularly referred to and used by our catering staff. Its programme has significantly improved the skill level and knowledge of my teams, and the practical, hands-on approach to demonstrate what food looks like, has been a great help to all 60 kitchens which operate within my area. The team at Premier Foods, led by Mark Taylor, has gone above and beyond our expectations and added real value to our business. 8 Dysphagia International Standards Dysphagia International Standards 9

Starting the day right Breakfast is the most important meal of the day and it is no different for those suffering with dysphagia. These two breakfast recipes will ensure your patients and residents dine with dignity and look forward to their first meal of the day. These recipes allow patients and residents who are suffering with dysphagia to have the same breakfast as those around them. Full English Breakfast Allergens: Sulphur Dioxide, Gluten, Egg, Milk, Celery, Sesame Kedgeree with Sharwood's Balti Sauce 0 Allergens: Fish, Egg, Milk, Nuts, Sesame, Celery 20 For the curried rice 1. Pulse the white rice in a blender to break up to mm, transfer to a sieve and rinse under cold water. 200g White rice 1ltr Bisto egetable Stock (made as per instructions) g Turmeric g Ground cinnamon 0g Unsalted butter g Fresh lemon juice For the smoked haddock 00g Skinless and boneless smoked haddock fillets 00g Full fat milk 0g Unsalted butter Salt and pepper (to taste) For the hard boiled eggs 3 Eggs For the curry sauce 00g Sharwood s Balti Sauce g Sosa Gelcrem Hot 0g Thick yoghurt For the spinach and chive purée x 0g Frozen spinach pellets 0g Thick yoghurt 0g Fresh chives g Lemon juice Food thickener (as required) Salt and pepper (to taste) Dysphagia International Standards 3½ hrs 2. Cook the rice in the Bisto egetable Stock, with the turmeric and ground cinnamon until cooked through and completely tender. 3. Drain and rinse under boiling water.. Place in a bowl and stir in the unsalted butter.. Finish with the lemon juice. Taste, season and keep warm to one side. 6. Poach the fish in the milk and butter until just cooked and flaky. 7. Remove and flake to the correct consistency of mm. 8. Keep warm. 9. Boil the eggs for 6 minutes and rest in the water for minutes.. Cool under cold water to stop them cooking and then peel. 11. For the curry sauce, bring the Sharwood s Balti Sauce to the boil in a pan. 12. Add the Sosa Gelcrem Hot. 13. Remove from the heat, add the yoghurt and blend until fine. Allow to stand for minutes and blend a second time. 1. Check the seasoning is correct and keep warm. 1. For the spinach and chive purée, heat the frozen spinach pellets and add the yoghurt. 16. Remove from the heat and add the chives and lemon juice. Blend to a fine purée, thicken as required and season. Plate the rice in a shallow bowl, space the haddock evenly across the surface, pipe the curry and spinach purées in the gaps, finely grate the egg over the top and serve. For the bacon 1. Start by preparing the bacon. Cut the vegetables and place in a pan with the smoked gammon hock, Bisto Ham Bouillon, bay leaves and peppercorns. 1 Onion 2 Carrots 00g Smoked gammon hock 1.ltrs Bisto Ham Bouillon (made up as per pack instructions) 2 Bay leaves Peppercorns For the sausage egetable oil (for frying) 0g Onion (diced) g Tomato purée 00g Lincolnshire sausage meat 200ml Bisto Gluten Free Gravy (made up as per instructions) Food thickener (if required) For the tomato 600g Homepride Tomato and Basil Sauce 20g Sosa Gelcrem Hot For the beans 00g Baked beans Food thickener (if required) For the mushroom 0g Onion (sliced) 0g Garlic (crushed) 0g Flat mushrooms (sliced) 0ml Bisto egetable Bouillon (made up as per instructions) Food thickener (if required) For the egg 9 Eggs 0ml Milk 0ml Cream Salt and pepper For the toast 67g Full fat milk 18g Bread (toasted) 1g Sosa egetal Setting Powder Salt (to taste) 2. Bring to a simmer and cook gently until tender and falling off the bone (this should take between 2.hrs 3.hrs). Remove the smoked gammon hock from the pan and cool slightly, reserving the stock. 3. Remove the skin and bone from the smoked gammon hock and flake into pieces before processing the meat in the blender until a smooth purée is formed, adding some of the reserved stock as needed.. Check the seasoning and complete Level texture checks (the texture can be adjusted by adding a food thickener or more stock if required). The bacon purée can be spread onto the plate or set into a mould before slicing thinly and reheating when needed.. To make the sausage, heat the vegetable oil in a pan and gently cook the onion for minutes, until soft. 6. Add the tomato purée and sausage meat and continue cooking for - minutes. 7. Pour in the Bisto Gluten Free Gravy and simmer for 30 minutes, until the sausage is cooked through and soft. Blend the mixture until smooth with no lumps. Check the seasoning and add food thickener (if required). Complete Level 8. To make the tomato, blend the Homepride Tomato and Basil Sauce to a fine purée and pass through a sieve. Heat the sauce and blend in the Sosa Gelcrem Hot. Leave to stand for minutes to thicken. 11. For the mushroom, sweat the onion and garlic until soft. Add the mushrooms and cook through. Add the Bisto egetable Stock and simmer for 2 minutes, then blend the mushrooms until smooth. Check the seasoning and complete Level If needed, food thickener can be added to adjust the texture. 12. For the egg, combine all the ingredients together in a metal bowl. Simmer a pan of water on the stove and place the metal bowl and egg mixture on top of the pan. Whisk continuously until egg mixture is thick and has reached 7 c before transferring to a blender and process until smooth. Complete Level 13. Heat the milk with the toast and vegetable setting powder, then blend to a smooth purée. Simmer for 2 minutes to activate the setting agent. 1. Immediately pour the toast mixture onto a tray lined with cling film, smooth out the mixture and cover with cling film which touches the surface to prevent a skin forming. Chill in the fridge for an hour, until set. Once cool, cut into toast shapes and reheat in a steamer. 1. Complete Level texture checks before serving (reheating for too long will cause the toast to melt and become unsuitable for this texture, steam for 3 ½ minutes until core temp is reached). 9. Complete Level texture checks (the texture can be adjusted by adding more food thickener or smooth Homepride Tomato and Basil Sauce, if required).. To make the baked beans, heat the baked beans thoroughly. Strain off the excess tomato sauce (keeping it to one side) and process the beans in a blender. Continue blending until smooth and add back in the excess tomato sauce until the desired texture is reached. Complete Level Dysphagia International Standards 11

Hearty lunchtime Lunchtime can be a distressing time for dysphagia sufferers, but with the below recipes and the presentation tips on page 11, you can ensure your patients and residents are looking forward to lunchtime and provide them with essential nutrients. egetable Korma with Mushroom and Tomato Dahl, Cucumber and Coriander Salad and Yoghurt Roast Chicken Dinner Allergens: Sulphur Dioxide, Milk, Celery Allergens: Milk, Mustard, Nuts, Celery, Sesame mixture The chicken d in a slow can be cooke r 1 hour. oven 10 c fo Minted Lamb casserole Allergens: Milk, Gluten, Celery, Wheat, Barley, Sulphur Dioxide 6 30-0 For the chicken 1. To make the chicken, heat the vegetable oil in a pan and add the onion, stir fry for minutes until soft and transparent.. Place all the ingredients on top of the parchment and fold in the edges to create a parcel. Twist the edges to seal. 2. Add the diced chicken and fry for 3 minutes. 11. Cook the parcel in the oven at 160 c for 30-0 minutes until soft and tender. 1 tbsp egetable oil 300g Onion, finely chopped 70g Diced chicken thigh meat (1.cm dice) 0g Paxo Stuffing 00ml Bisto Chicken Bouillon (made as pack instructions) Bisto Gluten Free Gravy For the smash 0ml Heated whole milk 0ml Boiling water 180g Smash g Butter Salt and ground white pepper For the honeyed carrots and parsnips 00g Diced carrots (1.cm dice) 00g Diced parsnips (1.cm dice) 0g Butter 0g Honey 1 Sprig of thyme Salt and pepper (to taste) For the broccoli 800g Broccoli (1.cm dice) 0g Butter 12 Dysphagia International Standards 3. Add the Paxo Stuffing and the Bisto Chicken Bouillon. Mix well and cook for 30 minutes until the chicken is soft and tender. Add more stock if required.. When the chicken is soft, thicken the sauce with the Bisto Gluten Free Gravy.. Complete Level 6 6. To make the smash, combine the heated milk and the boiling water, stir in the Smash and mix well. 7. Add the butter and season to taste. 8. Complete Level 6 9. For the honeyed carrots and parsnips, lay out a sheet of tin foil and baking parchment. 12. Complete Level 6 13. Cook the broccoli in a pan of boiling water until soft and tender. Strain and toss in the butter. 1. Complete Level 6 This recipe can be simply amended for other dysphagia Levels and. The chicken and vegetables can be cut into smaller pieces and cooked in the same way or puréed completely. For the vegetable korma 60g Root ginger (peeled and finely grated) 30g Crushed garlic 1ml egetable Oil 0g Onion (cut to mm cubes) 0g Carrot (cut to mm cubes) 0g Celeriac (cut to mm cubes) 0g Butternut squash (cut to mm cubes) 0g Sweet potato (cut to mm cubes) 600g Coconut milk 0g Double cream 0g Ground almonds Salt (to taste) 0g Sharwood s Korma Paste 00g Red lentils 00g Mushrooms (cut to mm dice) 10g Sharwood s Tikka Paste 0g Homepride Tomato and Basil Sauce 30g White wine vinegar 0g Sugar Salt (to taste) For the cucumber and coriander salad 00g Ripe avocado flesh 0g Coriander leaves 0g Cucumber g Fresh lemon juice Seasoning (to taste) 1. To make the vegetable korma, sweat the ginger and garlic in the oil over a moderate heat for 2 minutes. 2. Add the Sharwood s Korma Paste and continue to cook for 1 minute. 3. Add the vegetables and continue cooking for minutes.. Add the coconut milk and double cream and continue cooking until the vegetables are soft.. Stir in the almonds and reduce until thickened and season to taste. 6. Complete Level 7. To make the mushroom and tomato dahl, put 30 For the mushroom and tomato dahl the lentils, mushrooms, Sharwood s Tikka Paste and Homepride Tomato and Basil Sauce in a pan and bring to a simmer. 8. Cook for 1 minutes over a medium heat, stirring regularly, until the mixture thickens. 9. Stir in the vinegar and the sugar and season to taste.. Complete Level 11. For the cucumber and coriander salad, blend all the ingredients together until smooth, then season to taste. 1 For the minted lamb casserole 1ml egetable oil 1kg Lamb (finely minced) 10g Diced onion (mm) 10g Carrots (grated) 10ml White wine (optional) g Dried rosemary 1g Bisto Chicken Bouillon 00ml Bisto Gluten Free Gravy 1g Mint sauce Salt and pepper (to taste) Food thickener (if required) 1. Heat the oil in a pan and fry the lamb mince for - minutes until lightly coloured. 2. Add the onion, carrot, white wine and rosemary then reduce the liquid by half. 3. Add the Bisto Chicken Bouillon, Bisto Gluten Free Gravy and mint sauce and cook gently for minutes until the lamb is tender.. Season to taste and thicken with food thickener (if required).. Complete Level For the pea smash 0ml Water 00g Peas 0g Butter 60g Smash (dry) Salt and pepper (to taste) 6. For the pea smash, put the water in a pan and bring to the boil. 7. Add the peas and cook for 3 minutes. 8. Transfer the peas and water to a food processor and blend to a smooth purée with the butter. 9. Pour into a bowl and whisk in the dry Smash until fully combined.. Season to taste. Serve with any seasonal vegetables. Serve with thick yoghurt. Dysphagia International Standards 13

Tasty Teatimes The below recipes have been developed with teatime in mind, something savoury to provide patients with essential nutrients whilst allowing them to dine with their fellow residents with confidence, ensuring they look forward to their last meal of the day. Mac & Cheese Bolognese Allergens: Celery, Milk, Soya, Gluten, Mustard, Sesame Savoury Bread Pudding Allergens: Milk, Gluten, Egg, Wheat, Soya Coronation Chicken Salad Allergens: Mustard, Egg, Celery, Sesame, Nuts SERES 1 SERES 20 1 hrs SERES For the curried chicken g Sharwood s Korma Paste 0g Chicken breast 0g Raisins 200g Bisto Chicken Bouillon 7g Mayonnaise g Fresh lemon juice Food thickener (if required) g Curry powder g Turmeric powder Salt (to taste) For the apricot purée 00g Tinned apricots (drained) g Fresh lemon juice 0g Caster sugar 3g Sosa Gelcrem Hot For the rocket and avocado purée 00g Ripe avocado flesh 0g Rocket 0g Cucumber g Fresh lemon juice Salt and pepper (to taste) For the bolognese sauce 1ml Olive oil 00g Minced beef 10g Onion (diced) 10g Carrot (chopped) 1kg Homepride Bolognese Sauce Salt and pepper (to taste) For the mac and cheese 300g Cooked pasta (very soft) 200ml Bisto Béchamel Sauce (made as per instructions) 0g Mature Cheddar (grated) g Mustard Salt and pepper (to taste) 1. Pre-heat the oven to 10 c. 2. On the stove heat the oil in a heavy based casserole dish. Add the beef mince, season and cook until brown. 3. Add the onion and carrot then sweat for 2 minutes.. Add the Homepride Bolognese Sauce and cook in the oven for 1 hour or until the meat has softened and the sauce has thickened.. Check the seasoning and blend to a smooth purée before completing Level texture checks (if needed, a food thickener can be added at this stage). 6. For the mac and cheese, blend all ingredients together in a blender until smooth. 7. Season to taste and complete Level The bolognese is cooked for a longer time at a lower temperature oven to ensure the meat is tender and easier to blend to a purée. Pipe the bolognese purée into a serving dish then pipe small arc shapes on top to give the effect of macaroni. 700g Milk 300g Cream 200g Stilton cheese 17g Fresh breadcrumbs (made with McDougalls Soft Bap Mix) 3g Sosa Pro-Pannacotta 1. Blend all the ingredients together in a blender until smooth. 2. Bring to the boil and pour into ramekin dishes and leave to set. 3. Once set complete Level This recipe is based on a savoury bread and butter pudding. It can be easily adapted for Level by not blending the mixture and leaving the breadcrumbs for added texture. To adapt for Level 6, cut the bread into appropriate size pieces, instead of using breadcrumbs. Serve with smooth fruit chutney such as mango or tomato or try substituting the stilton with your favourite cheese. 1. Heat the Sharwood s Korma Paste with the curry and turmeric powder on a pan over a medium heat. 2. Fry the chicken in the paste for 2 minutes. 3. Add the raisins and Bisto Chicken Bouillon and simmer for 20 minutes or until the chicken is cooked through.. Transfer to a blender and process until smooth. Stir in the mayonnaise, lemon juice and thickener (if required).. Season to taste. 6. To make the apricot purée, blend the apricots to a fine purée with the lemon and the sugar. 7. Heat the purée to a boil. Add the Sosa Gelcrem Hot, and blend. 8. Allow to rest for minutes, and then blend again. 9. Check the texture and season if required.. To make the rocket and avocado purée, blend all of the ingredients together until smooth. 11. Taste and season and complete Level It is unusual to have a salad that is puréed and is a great addition to dysphagia menus as it offers variety. Try puréeing other salads such as beetroot and orange, tomato and basil or yoghurt, mint and lettuce. 1 Dysphagia International Standards Dysphagia International Standards 1

Delightful desserts Everyone enjoys a treat! These dessert recipes provide dysphagia sufferers with the opportunity to enjoy something sweet after their lunchtime or evening meal which is quick and easy to prepare for caterers. Bird s Lemon Ice Cream Allergens: Milk, Egg Passionfruit Pavlova gel is quite The passion l contrast il sour which w mer ingue et the super swe Apricot Crumble Allergens: Gluten, Milk, Egg, Wheat, Soya Allergens: Egg, Milk For the white meringue 1. Using a mixer, mix together the McDougalls Meringue Mix and water until fully dissolved. 9. Add the caramelised sugar in a steady stream whilst whisking on high speed. 2. Add the sugar in a steady stream whilst whisking on a high speed. Continue whisking until a full peak consistency is obtained.. Continue whisking until a full peak consistency is obtained. g McDougalls Meringue Mix 70ml Water 10g Sugar 1ml Cream For the caramelised sugar 1kg Sugar For the caramelised meringue g McDougalls Meringue Mix 70ml Water 10g Caramelised sugar 1ml Cream For the Ambrosia cream 200ml Cream 10ml Ambrosia Custard For the passion fruit gel 2g Passion fruit purée 0g Sugar g Sosa Gelcrem Cold 3. In a separate bowl whip the cream until soft peaks are formed.. Fold the two mixtures together and complete Level. To make the caramelised sugar, heat the sugar in a pan on the stove. 6. Take the sugar to a dark caramel then immediately remove from heat and pour into a metal tray to cool. 7. When cold, break the caramel up into pieces and transfer to a blender, blend to a powder and put to one side. 8. For the caramelised meringue, using a mixer, mix together the McDougalls Meringue Mix and water until dissolved. 16 Dysphagia International Standards 11. In a separate bowl whip the cream until soft peaks are formed. 12. Fold the two mixtures together and complete Level texture checks. 13. To make the Ambrosia cream, combine the cream and Ambrosia Custard and whip together until thick. 1. Complete Level 1. To make the passion fruit gel, blend all ingredients together until fully incorporated. 16. Complete Level Layer up on a dessert plate using piping bags with nozzles. Ice cream is not normally suitable for people with dysphagia as it will change consistency as it melts in the mouth. If ice cream is fluid there is a greater risk of aspiration. This recipe is designed to combat this. The ice cream does not melt and will remain a mousse consistency, even once defrosted. hrs 3 10g Bird s Ice Cream Mix 10g Full fat milk 300g Lemon curd 1. Combine the Bird s Ice Cream Mix and milk in a bowl. 2. Use an electric whisk until mixture has thickened and doubled in volume, this should take about minutes. 3. Fold the lemon curd and Bird s Ice Cream Mix together until combined.. Transfer to a container and deep freeze.. Complete Level texture checks before serving. 1 For the apricot filling For the crumble topping 1kg Tinned apricot (drained) 200g Caster sugar 3g Sosa Gelcrem Hot 00g McDougalls Crumble Mix 700g Ambrosia Custard For the apricot filling For the crumble topping 1. Blend the drained tinned apricot and sugar together. 2. Bring the purée to the boil and blend in the Sosa Gelcrem Hot. 3. Leave to stand for minutes and then blend again.. Complete Level texture checks. 1. Cook the McDougalls Crumble Mix until golden brown. 2. Blend the cooked crumble to a very fine crumb. 3. Add the Ambrosia Custard and blend until smooth.. Complete Level Serve with Ambrosia Cream. ariations of this dish can be made with other fruits such as apple, rhubarb, berries and pear. Some fruits (without seeds) could be cut and softened instead of pureeing to make suitable for Levels and 6. Dysphagia International Standards 17

Sensational Snacking Tomato Truffles Snacking is a great way to ensure your patients and residents are satisfied throughout the day. These simple and creative recipes provide them with something exciting to keep them going. Allergens: Milk, Sesame Smoked Salmon and Cucumber Allergens: Celery, Milk, Soya, Fish, Sulphites, Mustard Chocolate & Baileys Cupcakes Allergens: Milk, Egg, Gluten, Soya, Wheat SERES SERES 1 hr For the salmon mousse 20g Hot smoked salmon fillets (skinless and boneless) 17ml Bisto Béchamel Sauce (made up per instructions) 0g Horseradish sauce (sieved) g Sosa Gel Crem Cold (cut to mm cubes) Salt and cayenne pepper (to taste) Juice of 1 lemon For the cucumber juice 00g Cucumber (deseeded and chopped) For the tomato truffles 300ml Milk 30g Tomato purée 60ml Homepride Tomato and Basil Sauce (sieved and smooth) 26g Sosa Instangel g Salt 200ml Cream For the tomato jelly glaze 1ml Water 0ml Homepride Tomato and Basil Sauce (sieved and smooth) g Tomato paste 7g Sosa egetal Setting Powder Salt (to taste) Serve with puréed basil pesto. 1. To create the tomato truffles, blend together the milk, tomato purée, Homepride Tomato and Basil Sauce, Sosa Instangel and salt for 1 minute. 2. In a separate bowl whip the cream until soft peaks are formed. Fold the cream and tomato mix together. 3. Place in a piping bag and in the fridge for 30 minutes.. Pipe tomato mousse on to squares of cling film.. Gather cling film and tighten to create a tomato shape but then ensure the cling film is loosened so the mousse can easily be removed once frozen. 6. Freeze tomato mousses. 7. Once frozen remove from cling film and place cocktail sticks ready for dipping in tomato glaze (keep in the freezer and dip from frozen). 8. For the tomato jelly glaze, whisk together the water, Homepride Tomato and Basil Sauce and tomato paste. 9. Strain through a muslin cloth to remove all particles and create tomato water (after straining you will have a 200g yield).. Heat the tomato water in a pan with the Sosa egetal Setting Powder and season to taste. Bring to the boil and remove from the heat. 11. Remove the tomato mousse Freeze time: 1 hour moulds straight from the freezer. Dip in tomato jelly glaze solution twice back to back to ensure a nice amount of coverage. 12. Place on a tray and leave to defrost. Once defrosted remove sticks. 13. Complete Level texture checks and serve. You will need to have everything ready and work quickly when dipping the tomato mousse in the glaze as it will set very quickly. The tomato glaze should give a thin coverage on the mousse. It should be thin enough that you can squish with your tongue force alone and swallow as a single bolus. If the tomato glaze fractures into small pieces it will not be suitable for Level. 1. For the salmon mousse, blend together the salmon, Bisto Béchamel Sauce and horseradish sauce in a food processor until smooth. If needed push through a sieve to remove particles. 2. Season the mixture with salt, cayenne pepper and lemon juice. 3. Add the Sosa Gelcrem and mix well.. Leave to stand and thicken before completing Level. To make the cucumber juice, remove the seeds with a spoon and roughly chop the cucumber. Freeze before use (can be done in advance). Top tip: For the cucumber gel 300ml Cucumber juice g Sosa Gelcrem Cold g Sugar Salt (to taste) 6. Blend the cucumber to extract the juice and pass through a sieve to remove any particles. 7. For the cucumber gel, blend all ingredients together until fully combined. 8. Allow to stand for a few minutes to thicken, and then blend again to give a glossy finish to the gel. 9. Complete Level texture checks. To improve the presentation, freeze the salmon mousse into moulds and defrost on the plate before serving. SERES For the chocolate cake 00g McDougalls Chocolate Sponge Mix (cooked as per instructions) 00ml Ambrosia Custard Baileys (to taste) 1. Blend the cooked McDougalls Chocolate Sponge Mix to a fine crumb. 2. Add the Ambrosia Custard and Baileys then blend to a smooth purée. 3. Complete Level texture checks. Serve in cupcake cases with a spoon. -3 For the icing 17ml Double cream 10ml Ambrosia Custard Baileys (to taste). To make the icing, combine the double cream, Ambrosia Custard and Baileys.. Whip together until thick. 6. Complete Level texture checks. 18 Dysphagia International Standards Dysphagia International Standards 19

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